Anna Ratzliff

Teaching psychiatry residents to work at the interface of mental health and primary care

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

The Role of the Integrated Care Psychiatrist in Community Settings: A Survey of Psychiatrists’ Perspectives

OBJECTIVE The objective of this study was to describe the work and experiences of psychiatrists practicing integrated care in the community. METHODS Consulting psychiatrists working in integrated care participated in an online survey about their experiences, opinions, and advice. Results were analyzed with quantitative and qualitative methods. RESULTS A convenience sample of 52 psychiatrists from around the country who were working in integrated care responded. Respondents reported that they address a wide variety of clinical problems with a range of treatment strategies. Most reported positive experiences, which were summarized in four themes: working in a patient-centered care model, working with a team, the psychiatrists role as educator, and opportunities for growth and innovation. CONCLUSIONS The survey documented the experiences of psychiatrists working in integrated care. Findings suggest that integrated care teams allow consulting psychiatrists to leverage their expertise to reach a large number of patients in a variety of practice settings.

A Collaborative Care Approach to Depression Treatment for Asian Americans

OBJECTIVE This study examined effectiveness of collaborative care for depression among Asians treated either at a community health center that focuses on Asians (culturally sensitive clinic) or at general community health centers and among a matched population of whites treated at the same general community clinics. METHODS For 345 participants in a statewide collaborative care program, use of psychotropic medications, primary care visits with depression care managers, and depression severity (as measured with the nine-item Patient Health Questionnaire) were tracked at baseline and 16 weeks. RESULTS After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes. Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications. CONCLUSIONS Collaborative care for depression showed similar response rates among all three groups.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for “safety-net” patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question “How could psychiatric consultation [in the program] be improved?” Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Practical Approaches for Achieving Integrated Behavioral Health Care in Primary Care Settings

Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability.

Building value-added teams to care for behavioral health needs in primary care

Collaborative care has emerged as an evidence-based approach to care for patients with common mental health disorders such as depression or anxiety in primary care. To deliver successful collaborative care, a program must build a team with effective “shared workflows.” A psychiatrist functioning in a mental health leadership role may play an important role in the development, implementation, and ongoing improvement of a high-functioning collaborative care team. The process of building such a team involves several stages: leadership commitment, preparing for team building, developing a clear vision for the scope of the program, assessing current resources and workflows, conducting a gap assessment to identify staff and training needs, generating a collaborative care workflow, training staff, program launch, and supporting the ongoing quality improvement efforts of the team.

Tele-Behavioral Health, Collaborative Care, and Integrated Care: Learning to Leverage Scarce Psychiatric Resources over Distance, Populations, and Time

With significant unmet population health needs for mental health care and a continued shortage of psychiatric providers, future psychiatrists will increasingly need education in new care delivery approaches that address these problems, especially for individual patient care delivery such as telebehavioral health and integrated care. These educational needs can be conceptualized as clinical skills for different modalities of individual patient care and leadership abilities to use systematic approaches to provide population-based care. In this column, we review key learning needs, educational strategies, and available resources to support educators in their curriculum development and implementation activities for the delivery of these emerging approaches to psychiatric care. While there is a growing need to train graduate learners in integrated care(IC)/collaborative care model (CoCM) and tele-behavioral health (TBH), one significant and often overlooked challenge is that faculty members who are called upon to supervise may not themselves have experience or training working in this area. Faculty members require not only the ability to provide these types of care but also the ability to teach, supervise, and assess trainee performance in these areas. Many of the resources we identify as relevant for trainees could also be useful for faculty members starting out in this area. Faculty members could also consider creatively pursuing different professional development opportunities with transferable competencies relevant to new care delivery models based on their individual learning needs and the available educational opportunities in their setting, for example training in the areas of public health, leadership, quality improvement, and/or education scholarship. In this article, we also aim to identify some practical, readily available teaching and assessment resources so that newer faculty can use and/or adapt them without having to “reinvent the wheel.”

Financing for Collaborative Care—a Narrative Review

Opinion statementPurpose of reviewCollaborative care (CoCM) is an evidence-based model for the treatment of common mental health conditions in the primary care setting. Its workflow encourages systematic communication among clinicians outside of face-to-face patient encounters, which has posed financial challenges in traditional fee-for-service reimbursement environments.Recent findingsOrganizations have employed various financing strategies to promote CoCM sustainability, including external grants, alternate payment model contracts with specific payers, and the use of billing codes for individual components of CoCM. In recent years, Medicare approved fee-for-service, time-based billing codes for CoCM that allow for the reimbursement of patient care performed outside of face-to-face encounters. A growing number of Medicaid and commercial payers have followed suit, either recognizing the fee-for-service codes or contracting to reimburse in alternate payment models.SummaryAlthough significant challenges remain, novel methods for payment and cooperative efforts among insurers have helped move CoCM closer to financial sustainability.

Collaborative care for a patient with bipolar disorder in primary care: a case example

OBJECTIVE The objective was to describe the process of care and treatment outcomes of a 36-year-old man with bipolar disorder treated using a collaborative care model in primary care. METHODS We reviewed and summarized relevant clinical data describing the patients care including the medical record, consultants reports and discussions with treating clinicians. A meeting was held with experienced consulting psychiatrists to discuss the case. RESULTS Several barriers to delivery of high-quality care existed including initial loss to follow-up, few social supports and lack of follow-through at the community mental health center existed, along with presence of factors that negatively influence bipolar disorder outcomes including initial unopposed antidepressant use at baseline, concurrent alcohol use and co-occurring anxiety symptoms. Despite these barriers, the collaborative care team was able to engage the patient in care and achieve the patients and teams treatment goals. CONCLUSION Delivery of primary-care-based collaborative care was associated with reduction of bipolar disorder symptoms and improved functioning in a patient with bipolar disorder.